What are the essential components to include when writing a case report?

Essential Components for Writing an Effective Case Report

A comprehensive case report must follow the SCARE (Surgical CAse REport) guidelines, which provide a structured framework for reporting clinical cases with detailed information about patient presentation, diagnosis, intervention, and outcomes. 1

Core Components of a Case Report

Title and Abstract

• Title: Must include the words "case report" and describe the specific focus area (presentation, diagnosis, technique, or outcome) 1
• Keywords: Include 3-6 relevant keywords (with "case report" as one of them) 1
• Abstract: Must contain:
  • Introduction explaining what makes the case unique or educational
  • Patient's main concerns and important clinical findings
  • Main diagnoses, interventions, and outcomes
  • Conclusion with key "take-away" lessons 1

Introduction

• Summarize why the case is unique or educational
• Reference relevant literature and current standard of care
• Keep to 1-2 paragraphs with appropriate citations
• Mention the type of institution where patient was managed (academic, community, private) 1

Patient Information

• Demographics: De-identified patient details (age, sex, ethnicity, occupation, BMI if relevant)
• Presentation: Detailed description of presenting complaints, symptoms, and mode of presentation
• Medical History: Past medical/surgical history and outcomes from previous interventions
• Other History: Medication history, allergies, family history, psychosocial factors 1

Clinical Findings

• Detailed description of physical examination findings
• Include relevant clinical photographs (with patient consent)
• Document all significant positive and negative findings 1, 2

Timeline

• Chronological sequence of events from presentation to intervention
• Include delays between presentation and intervention
• Consider using tables or figures to illustrate the timeline 1

Diagnostic Assessment

• Methods: All investigations performed (physical exam, laboratory tests, imaging, histopathology)
• Challenges: Any diagnostic difficulties encountered (access, financial, cultural)
• Reasoning: Differential diagnoses considered and rationale
• Prognostic factors: Include staging information when applicable (e.g., tumor staging) 1

Therapeutic Intervention

• Pre-intervention: Patient optimization measures taken before intervention
• Interventions: Types of interventions used and reasoning behind treatment choices
• Details: Specific procedural information (anesthesia, position, equipment, techniques)
• Provider information: Experience level of the person performing the procedure
• Changes: Any modifications to planned interventions with rationale 1

Follow-up and Outcomes

• Clinician-assessed and patient-reported outcomes with timeframes
• Important follow-up measures and test results
• Treatment adherence and tolerability
• Complications and adverse events (ideally categorized using Clavien-Dindo Classification) 1

Discussion

• Strengths, weaknesses, and limitations of the approach
• Relevant literature review and implications for practice
• Rationale for conclusions
• Primary "take-away" lessons 1

Additional Required Elements

• Patient Perspective: When appropriate, include the patient's experience
• Informed Consent: Document that informed consent was obtained for publication
• Conflicts of Interest: Disclose any potential conflicts 1

Best Practices for Case Report Writing

Focus on Relevance and Conciseness

• Ensure the case warrants publication by offering new insights or educational value
• Include only pertinent positive and negative findings
• Avoid irrelevant material or excessive detail that obscures the essence of the report 2

Enhance Educational Value

• Use illustrations, tables, and graphs to add visual appeal and clarity
• Make visual supplements simple, compact, and self-explanatory
• Include only essential citations that you have carefully reviewed 2

Maintain Scientific Rigor

• Present information in a factual, logically organized manner
• Avoid unjustified speculation
• Draw conclusions only when warranted by the evidence presented 2, 3

Common Pitfalls to Avoid

• Focusing only on the rarity of a disease without providing clear learning points 4
• Including irrelevant patient information that doesn't contribute to understanding the case
• Inadequate literature review to contextualize the case's significance
• Failing to obtain proper informed consent for publication 1

By adhering to these structured guidelines, clinicians can produce high-quality case reports that contribute meaningfully to medical literature and enhance clinical practice.